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Guidelines – Healthcare

2006 AIA FGI


Highlights

August 2006
Paula Buick
Perspective
Technological Integration
1954 marked the
beginning of
production for the
Ericofon. Originally it
was intended for
institutional use. They
found their biggest
customers were
hospitals. Imagine
laying in a hospital
bed, trying to reach
over to a desk phone
to dial. The one piece
design of the Ericofon
seemed to be "just
what the doctor
ordered". Silk sheets
optional.
Knowledge
Guidelines 2006
Who
The Facility Guidelines Institute – FGI
AIA Academy of Architecture for Health AIA/AAH
With
U.S. Department of Health and Human Services

Funded
DHHS/CMS, ASHE and NIH

Changes
Bigger 175 pages to 325
Better format, legible, indexing and searching – CD – Punched
numbering [Clemson] and ‘Appendix’
Organization 4 Sections - ”All” - Hospitals - Ambulatory – Others
Process Request Formal Interpretation and Change
1 General
Section 1
Introduction – What, Why, Who, Major Additions Summary
Interpretation
Referenced Codes Listing, Web Sites

Code Life Safety CMS adopted NFPA 101


Renovation NFPA 101 covering HCO -’affected areas’
NFPA 101 New HCO or Existing HCO
ADAAG Accessibility Guidelines for Bldgs and Facilities
Information Protection – HIPPA

Disaster Types Facility Response

Appendix – shaded boxes throughout is advisory only


* not changed from 2001 Guidelines
Overall Organization
Part 1 General 34 pages [17] - national codes, standards; EOC; Equip, D&C …
Part 2 Hospitals 151 pages [83 total-58+11+14]
2.1 General Hospitals ** bed clearances ICUs -Intermediate Care –freestanding ED – MRI – Waste – AI PE new language air
2.2 Small Primary Care Hospitals ***
2.3 Psychiatric
2.4 Rehabilitation
Part 3 Ambulatory Care Facilities 63 pages [23]
3.1 Outpatient [OP] Facilities
3.2 Primary Care OP Centers
3.3 Small Primary Neighborhood OP Facilities
3.4 Freestanding OP D&T Facilities
3.5 Freestanding Urgent Care Facilities
3.6 Freestanding Birthing Centers
3.7 OP Surgical Suite
3.8 Office Surgical Facilities ***
3.9 Gastrointestinal Endoscopy Facilities ***
3.10 Renal Dialysis Centers ***
3.11 Psychiatric OP Centers ***
3.12 Mobile, Transportable and Relocatable Units [use of means other than covered walkways shall be permitted]

Part 4 Other Health Care Venues 43 pages


4.1 Nursing Facilities
4.2 Hospice Care **
4.3 Assisted Living **
4.4 Adult Day Care **
1 General
1.2 Environment of Care significant expansion p15-20
Delivery of Care model shall be defined in the functional program [pt.focused/ family
centered/ community centered]
Light and Views, Clarity of Access [wayfinding], Control of Environment,
Privacy, Finishes [color palette] Water features – Aquariums – IAQs

2.2.2.5 Physical Environment


2.2 Nomenclature – names and spaces indicated on the functional program shall
be consistent with the submitted floor plan

3 Sustainable Design – Site, Waste Minimization, Water quality-


Conservation, Energy.. IAQ
VOCs – moisture – dedicated exhaust systems

1.4 Equipment*
Equipment list included in contract documents
Equipment list specify new, existing to be relocated, owner provided NIC
1 General
1.5 Planning Design Construction p26
Interdisciplinary Design Team, Commissioning
1.5.2 Infection Control Risk Assessment Process
2.1.3. Monitoring The owner shall also provide monitoring
of the effectiveness of the applied ICRMR during the course of
the project
2.2.1 Design Location of special ventilation and filtration such as ED
waiting and intake areas
2.2.1.3 Air handling, ventilation needs in surgical svs, AI, PE, Labs etc
2.2.1.5 Finishes and Surfaces
2.2.2. Construction location of susceptible pts; Impact of potential
outages or emergencies and protection of pts during planned or
unplanned ..
2.3 Infection Control Risk Mitigation
2.3.2 Project Requirements the owner shall ensure that construction
related ICRMR as well as ICRA-generated design recommendations, are
incorporated into the project requirements
2.3.3 IC Monitoring The owner … provide continuous monitoring of their
effectiveness …
2.3.3.1. … may be conducted by in-house IC&S staff or independent
Reference Site: CDC
http://www.cdc.gov/ncidod/dbmd/diseaseinfo/default.htm
Aspergillosis -
Clinical Features
In immunosuppressed hosts: invasive pulmonary infection, usually with fever, cough, and chest pain.
May disseminate to other organs, including brain, skin and bone. In immunocompetent hosts:
localized pulmonary infection in persons with underlying lung disease. Also causes allergic sinusitis
and allergic bronchopulmonary disease.
Etiologic Agent Aspergillus fumigatus, A. flavus. Less commonly A. terreus, A. nidulans, A. niger.
Reservoir Ubiquitous in the environment. Found in soil, decomposing plant matter, household dust,
building materials, ornamental plants, items of food, and water.
Incidence Not reportable. Population-based data available for San Francisco suggest a rate of 1-2 per
100,000 per year.
Sequelae If severe granulocytopenia persists, mortality rate can be very high (up to 100% in patients
with cerebral abscesses). Patient outcome depends on resolution of granulocytopenia and early
institution of effective antifungal drug therapy.
Transmission Inhalation of airborne conidia (spores). Nosocomial infection may be associated with
dust exposure during building renovation or construction. Occasional outbreaks of cutaneous
infection traced to contaminated biomedical devices.
Risk Groups Persons with severe, prolonged granulocytopenia (e.g., hematologic malignancy,
hematopoietic stem cell and solid organ transplant recipients, and patients on high-dose
corticosteroids). Rarely, persons with HIV infection.
Surveillance No national surveillance exists.
Challenges Identifying modifiable risk factors for disease in immunocompromised persons. Improving
understanding of sources and routes of transmission from the environment.
Aspergillus
http://www.aspergillus.org.uk/secure/articles/webbarnes.htm
Sources of infection: endogenous versus exogenous
A major issue in the prevention of nosocomial aspergillosis is the question of whether infection in an individual patient was acquired in hospital, or in the
community: our most energetic prevention efforts in the hospital will not prevent the latter. There are many uncertainties in this area, not least the
incubation period of the disease (estimated to vary from 48 hours to 3 months). Some light has been shed by the use of molecular typing methods
(2,15,16,19). If the criterion used for "hospital-acquired infection" is the isolation of the same fungal strain from the patient and the environment,
some 40 % of cases of invasive aspergillosis appear nosocomial (19). Further use of increasingly accurate typing methods will help to elucidate this
question in the future.
Prevention of nosocomial aspergillosis:
Outbreaks of nosocomial aspergillosis occur mainly among neutropenic patients. These have occurred in association with environmental disturbances:
hospital construction; contaminated fire-proofing materials, or air filters in the hospital ventilation system; contaminated carpeting.
Routes of transmission: airborne route
The first evidence for the protective effect of air filtration ..The recognition of a high incidence of aspergillosis in the hospital's BMT patients led to the
installation of high-efficiency particulate air (HEPA) filters. This was associated with a dramatic fall both in environmental counts of Aspergillus sp,
and in cases of invasive disease (14).
..reports show that modern ventilation and filtration systems are capable of dramatically reducing aspergillus spore counts.(4,7)
In summary, the prevention of nosocomial aspergillosis involves the proper installation, use, and maintenance of ventilation systems; and the elimination
of exposure to fungal spores generated by construction.(1,15,16) The environmental controls required to protect vulnerable patients are detailed in
the CDC recommendations, shown in tables 1 and 2. Table 1 shows the measures needed to minimize exposure to fungal spores to produce the
"protected environment" required for neutropenic patients: essentially HEPA filtration, directed air flow, positive pressure, a well sealed room, and
high rates of room air changes.
Table 2 contains the full guidelines on prevention and control. Section 4 pertains to existing facilities with no cases of nosocomial aspergillosis: a couple of
additional points may be made. It is worth emphasising the importance of preventing dust-accumulation by daily damp-dusting of horizontal
surfaces. Some authorities feel that mould proliferation around sink outlets, etc, may represent another environmental reservoir: so water leaks
should be cleaned up and repaired. BMT units should minimize exposure of patients to activities such as carpet cleaning or vacuuming, that may
cause aerosolization of Aspergillus spores, and the ward vacuum cleaner should be fitted with HEPA filters.
When construction is undertaken, the measures suggested to protect vulnerable patients include the use of impermeable barriers between patient care and
construction areas; directing pedestrian traffic away from the area to prevent dust dispersal; and cleaning of the new premises before patients are
moved there. Finally, air and environmental monitoring for spores may be indicated when building works are taking place adjacent to an area
housing high-risk patients.

Is water a source of Aspergillus?


At this point, we should consider the recent suggestion that hospital water supplies may be a source of Aspergillus species spores. They concluded that
showering resulted in aerosolization of spores and was a potential source of exposure (17). The Norwegian-led group of Warris and colleagues
carried out a study in a paediatric BMT unit, sampling water from the taps in the unit as well as the mains supply. Filamentous fungi were recovered
from all water samples, Aspergillus fumigatus from 60 % of tap samples (18). These results are of considerable interest, but larger scale studies are
required.
1 General
1.6 Common Requirements p31
2 Building Systems
2.1.2 Plumbing
Hot water recirculation – constant and non recirc <= 25’
Dead end piping [branches with no fixtures] shall not be installed. Empty
risers, mains & branches permitted
2.3 Electrical
Lighting IES [Illuminating Engineering Society] references
Pub RP-29 Lighting for Hospitals and Healthcare
Pub RP-28 Needs of elderly Visual Environment for Senior Living
2. General Hospitals p37 -134
Swing beds – Patient-Family Centered Care Rooms – AirFlow – Staff
Emergency Assist location – Pts Observation – Documentation –
Obstetrical Models – Surge Capacity – Fast Track – DeContam –
3. Nursing Locations
3.1 Medical Surgical Rooms
3.1.2 Patient/Family Centered Rooms
3.2.5 Protected Units – transplant, nurseries, NICU, parts of ED

3.3 Intermediate Care Units – ‘Step Down’ ->med/surg<ICU


3.3.1.3 Location …can be sep unit or designated part of ..

3.4.6 NICU
3.4.6.1. Space requirements 120 sf and aisle adjacent to each min 4’
in multips. Single or fixed cubicle partitions aisle not less
than 8 feet in clear and unobstructed width…

4.1 Obstetrical
4.4. LDR LDRP – single occupancy [min clear 300 sf – 2001 – min
dimension 13’ exclusive closets etc] Dimension 15’preferable
2.1 General Hospitals p 37 -134

3.1.1 Capacity p 40
New construction max 1 unless functional program demonstrates….Approval of a 2
bed shall be obtained from the licensing authority

New Single Rooms Construction


3.1.1.2 Space Requirements*
(1) Area 120 sf Clear Floor Area
exclusive of toilet rooms, closets, wardrobes, alcoves or vestibules
[ExTC]
(2) Dimensions Clearances 3’ Foot - 3’ - 3’
(3) Renovation waiver – AHJ 80 sf multips/100 sf singles

3.1.1.2 Single Pt Rooms


12’ wide x 13’ deep
REQ REC
~ 160 sf exclusive of toilet rooms, closets,
120 160
clear clear

* 2001 AIA 3.3.3


2.1 General Hospitals

3.1.2 Patient/Family Centered Care Rooms p41


3.1.3 Space Requirements
Area 250 sf Clear Floor Area ExTC
Dimensions Min clear 15 feet
Additional area 30 sf per family member

30

250
clear

15
2. General Hospitals

3.4 Critical Care Units p49


3.4.2.1. Space Requirements
Area 200 sf Clear Floor Area [ExTC]*
Dimensions Min Headwall 13’ *
Clearances 5’ foot - 5’ transfer side - 4’ non transfer side
Renovation if not possible –AHJ waiver min 150 sf
Observation – Documentation

5 13

200
clear 5.5.4
Where to put it ?
Where to put it ?
2. General Hospitals
5. Diagnostic and Treatment Locations
5.1 Emergency Service p68
Surge Capacity .. Up to 10 or a fourhold increase …
Adjacent space for triage and management
Utility upgrades for those areas – Oxy H2O Electrical
Exhaust – ventilation – routes to admission
Classification of Emergency Departments/Services/Trauma Centers
www.facs.org American College Surgeons
www.acep.org American College Emergency Physicans

5.1.3 Fast Track Area .. 20-30k visits p70


5.1.3.7.(5) Decontamination p73 – location, space min 80 sf clear floor,
surface specs
5.1.3.7. (5) Decontamination Area on the Exterior Perimeter
Markings, showerheads, secured access tel systems, airflow &
ventilation, H2O runoff,
Decontamination Area Interior – specified dimensions – ceilings wall
and floors,
2. General Hospitals
5. Diagnostic and Treatment Locations
5.1 Emergency Service
5.1.3.8 (2) Observation/Holding Units p74
Area 100 sf clear floor
Dimensions 
Clearances 
HW Sink 1:4 or fraction
Toilet 1:8 or major fraction
Nourishment

5.1.3.11 (1) Bereavement Room


STC 65 walls 45 floors & ceiling

Refer to STC sound table p 129


2. General Hospitals
‘8 feet’ corridors*
2. General Hospitals
5. Diagnostic and Treatment Locations
5.3 Surgery
5.3.2 Operating and Procedure Rooms – Class A, B C* p77
new Construction (d) op Rooms perimeter walls, ceilings and floors including
penetrations shall be sealed

5.3.3. Pre- And Post Operative Holding Areas* P79


Space Requirements
Area 80 sf 80
Clearances 4’4’4’
4.4.4
5.3.3.2 PACU’s* 4
5
Space Requirements
Area 80 sf 80 80
Clearances 5’4’4’
w

Separate and additional recovery space may be necessary to accommodated patients.


If children receive care, recovery space should be provided for pediatric patients and
the layout of the surgical suite should facilitate the presence of parents in the PACU
2. General Hospitals
3. Ambulatory Care
3.7 Outpatient Surgical Facilities Surgical Procedure Rooms* p 222
Defined by American College of Surgeons

Class A Class B Class C


Minor Minor/Major Major
Topical Oral General
Local Parenteral
Regional
No IV Spinal
Epidural IV
150 sf ExVC 250 sf ExVC 400 sf ExVC
min clear 12’ min clear 15’ min clear 18’
3’6” side foot head 3’6” side foot head 4’ side foot head

Note: 2.0 General Hospital 5.3 Surgery 5.3.2 Operating and Procedure Rooms – Class A, B C* p77
2. General Hospitals
5. Diagnostic and Treatment Locations
5.3 Surgery
5.3.2 Operating and Procedure Rooms – Class A, B C* p77
5.3.2.1 General Operating Rooms*
New - (d) Renovation
5.3.2.2 Special [CardioVascular Ortho Neuro]* p78
5.3.2.4 Surgical Cystoscopy Rooms*

New Renovation Special Special


New Renovation

400 sf ExC 350 sf ExC 600 sf ExC Ortho 360 sf


min clear 20’ CV/Neuro 400
min clear 20’ min clear 15’
min clear 18’
Surgical Cysto
350 sf ExC UroCysto 250
min clear 15’
2. General Hospitals
5. Diagnostic and Treatment Locations
5.3 Surgery - Summary Peri-Op
5.3.3. Pre- And Post Operative Holding Areas* P79
Space Requirements
Area 80 sf
Clearances 4’4’4’
5.3.3.2 PACU’s* Mass DPH Ratio 3:1 OR
Space Requirements
Area 80 sf
Clearances 5’4’4
5.3.3.3 Phase II Recovery* Mass DPH min 50% of PACU requirement
Lounge Chair Area 50 sf Clearance 4’4’4’ HW Sink 1:4 Chairs
Single Room Area 100 sf clear Clearance  HW Sink Req

4
5
80 80 50 50
80 80 100
4.4.4 4.4.4 w 4.4.4. 4.4.4.
Pre & Post PACU Phase II Single
2. General Hospitals
STC sound table p 129
2. General Hospitals
5. Diagnostic and Treatment Locations
5.4 Interventional Imaging Facilities p82
5.4.1 Cardiac Cath lab located in Imaging suite permitted
Area 400 sf clear floor ExC
Dimensions 
Clearances 
5.5.1 Imaging Suite General* p83
5.5.2 Angiography* p84
A5.2.1.1 (1) The procedure room should be min 400 sf
A5.2.3 Viewing areas should be min 10’ length
A5.4.1 Radiographic rooms should be min 180 sf [dedicated chest smaller]
A5.4.2 Tomography and radiography/fluroscopy (R&F) rooms min 250 sf
A5.5.4.3 Mammography rooms min 100 sf
A5.5.5.3 MRI Control Rooms min 100 sf and may be larger
5.5.6 Ultrasound*
5.5.7 Cardiac Cath Lab*
5.6 Nuclear Medicine*
A5.6.3 PET Facilities Space Requirements
2. General Hospitals
General Finishes p 113
8.2.3.2 Flooring*
8.2.3.7 PE and Anterooms
shall have seamless flooring with integral coved base

8.2.3.4 Ceilings p 113


Semi-Restricted [AI- PE – Specialized Radiology, Minor Surgical Class A…]
Smooth Scrubbable NonPerforated
If lay in … gasketed and clipped

10.2.2.2 Protective Environment Rooms p 120


(4) If AI is necessary for PE patients an ante-room shall be provided

10.2.2.4 (3) (a) Operating and Delivery Room Ventilation p 120


Rec air changes 20-25 ACH ceiling heights between 9’ and 12’
Refer to appendix on this page for more details [NIH –ASHRAE Transactions
2002 Vol 108 pt 2]
2. General Hospitals
10.1 Plumbing
10.1.2.5 (2)(b) Floor Drains Cysto Operating Rooms – if insisted upon ….
Location and instructions to prevent trap dry out…
10.2 Heating Ventilating and HVAC Systems p 118
10.2.1.1 Mechanical System Design (2) Air Handling Systems
(5) Renovation – if modification affects > 10% system capacity…. Designers
shall Utilize pre- renovation water/air flow rate measurements to verify that
sufficient capacity is available and that renovations have not adversely affected
flow rates in non-renovated areas
10.2.1.3 Testing & Documentation –’owner shall be furnished’
10.2.2 Specific Locations AI rooms (1) design.. Permitted .. to include
provisions for normal patient care during periods not req isolation
Remodeling Guidance 118, Operating Rooms 120, Anesthetic Agents 122

10. 5 Electronic Safety and Security Surveillance Systems p 129


10.5.1. Electronic Surveillance Systems
Door, Access Control, AV monitoring, Pt Location, Infant Abduction
10.5.1.1 Devices are not required but if.. Unobstrusive, tamper resistant
10.5.1.2 … devices located so not readily observable by general public or patients
10.5.1.3 … emergency electrical system
2. General Hospitals
3. Ambulatory Facilities
3.9 GI Endoscopy Facilities p 233
1.2 Functional Program – description … hours…
1.4 Shared Services [IP-OP] - services may be shared to avoid duplication
1.4.2 If IP OP are performed same room, functional program should describe
in detail scheduling and techniques used to separate IP and OP
2.3.1 Procedure Rooms
Area 200 sf ExVTC
Clearances 3’6” side head foot of stretcher/table
2.3.2 Patient Holding/Prep/Recovery Area
2.3.2.1 General (1) meets the size requirements of a stepdown recovery area
[3.7-2.4.2.1]

4
5

80 80 100

w GI prep/recov Single
2. General Hospitals
3. Ambulatory Facilities
3.9 GI Endoscopy Facilities p 233
3.2 Instrument Processing Rooms P 235
Dedicated processing room(s) for cleaning and decontaminating
instruments shall be provided.
3.2.1.3 Layout The cleaning area shall allow for the flow of instruments from
the contaminated area to the clean assembly area and then to storage. A
physical barrier shall be provided to prevent droplet contamination on the
clean side.
A3.2.2.1 This may require soaking sink(s), rinse sink(s, automated cleaning
device(s), or a combination.

5. Construction Standards
5.2.1.1 Corridor Width (1) min public 5’ except where pts are transported on
stretchers shall be 8’ [Doors 3’8”]
(2) Staff access corridors may be 3’8” [Doors 3’]
Exam Room Table 60 years ago
3.0 Ambulatory Care Facilities p 189

3.1 Outpatient Facilities


3.1.2 Exam rooms* p 190
Area 80 sf clear floor 80 sf Clear
Dimensions 
Clearances 2’8” * sides foot exam table
3.1.2.2 Special Purpose Rooms – Eye ENT
Area 80 sf clear floor
2.82.82.8
Dimensions 
Clearances 2’8”sides foot table, bed or chair
3.1.3 Treatment Rooms [ExTC]*
Area 120 sf clear floor*
120 sf Clear
Dimensions Minimum 10’ clear
Clearances 3’ 0” sides foot bed
HW sink 10’ min

3.1.4 Observation Rooms [rooms to isolate suspect, 3.3.3


disturbed pts]
Area 80 sf clear floor [ExTC]
Dimensions 
Staff – Lounges, Lockers – where are they?

Clinical – Pharmacy – Lab – Dietary ..